Provider Demographics
NPI:1912154774
Name:BROOKFIELD PRESCRIPTION CENTER INC
Entity Type:Organization
Organization Name:BROOKFIELD PRESCRIPTION CENTER INC
Other - Org Name:MD CUSTOM RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZATARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-373-1050
Mailing Address - Street 1:19035 W CAPITOL DR
Mailing Address - Street 2:STE 102
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2755
Mailing Address - Country:US
Mailing Address - Phone:262-373-1050
Mailing Address - Fax:262-373-1053
Practice Address - Street 1:19035 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2755
Practice Address - Country:US
Practice Address - Phone:262-373-1050
Practice Address - Fax:262-373-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-24
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301010339333600000X
WI8844-423336C0003X
IL0540176463336C0003X
MN2636543336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2116685OtherPK